Company

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Have you ever sold to us before?

Have you ever sold to us before?*

Yes

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What are you trying to sell?

What are you trying to sell?*

Box of Strips

CGM Device

Both

Provide more information about your box(es) of strips.

Add New Box

Brand	Type	Expiration Date	Condition of Box	Upload an image (optional)	Does this box have a label that says "Medicare/Medicaid Use Only”?	Actions

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Provide more information about your CGM device(s).

Add as many boxes as you have devices to send.

Add New Box

Brand	Type	Condition of Box	Upload an image (optional)	Does this device have a label that says "Medicare/Medicaid Use Only”?	Actions

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How often do you plan on sending us items?

How often do you plan on sending us items?*

Just Once

Once a Month

Quarterly

Twice a Year

I’m Not Sure

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Referral Email

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First name*

Last Name*

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Address*

Address Address Line 2 (apt number, unit number, etc) City State ZIP Code

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